Sleep quality in Lyme disease

Complaints of chronic fatigue as well as sleep disturbances are prevalent in Lyme disease. We compared polysomnographic measures of sleep in patients with documented Lyme disease with those of a group of age-matched normal control subjects. Eleven patients meeting Centers for Disease Control criteria for late Lyme disease with serologic confirmation by enzyme-linked immunosorbent assay and Western blot without a history of other medical or psychiatric illness and 10 age-matched control subjects were studied. Lyme disease patients and controls underwent 2 nights of polysomnography. Multiple sleep latency testing (MSLT) was performed in the patients. Sleep was staged by standard criteria, and continuity of sleep was assessed for each stage of frequency analysis of consecutive epochs. All patients studied reported sleep-related complaints, including difficulty initiating sleep (27%), frequent nocturnal awakenings (27%), excessive daytime somnolence (73%) and restless legs/nocturnal leg jerking (9%). Greater sleep latency, decreased sleep efficiency and a greater arousal index were noted in Lyme patients. The median length of uninterrupted occurrences of stage 2 and stage 4 non-rapid eye movement (NREM) sleep was less in Lyme patients (6.3 +/- 3.0 epochs in patients vs. 11.4 +/- 4.4 epochs in controls for stage 2, p < 0.01, and 4.3 +/- 4.4 epochs in patients vs. 11.2 +/- 6.3 epochs in controls for stage 4, p < 0.01), indicating greater sleep fragmentation. Mean sleep onset latency during the MSLT was normal (12.7 +/- 5.6 minutes). Three patients demonstrated alpha-wave intrusion into NREM sleep. These sleep abnormalities may contribute to the fatigue and sleep complaints common in this disease.     

Utility of nocturnal home oximetry for case finding in patients with suspected sleep apnea hypopnea syndrome

OBJECTIVE: To evaluate prospectively the validity of home oximetry for case finding in patients clinically suspected of having the sleep apnea hypopnea syndrome (SAHS). DESIGN: Blinded comparison of home oximetry and polysomnographic nocturnal recordings. SETTING: Sleep clinic of a tertiary referral center. PATIENTS: A total of 240 outpatients referred because of reported sleep disturbances or daytime hypersomnia compatible with the diagnosis of SAHS. MEASUREMENTS: All participants had nocturnal home oximetry followed by a conventional polysomnographic study. The two recordings were interpreted blindly. Home oximetry test results were classified as abnormal (suspicion of sleep-related breathing abnormalities) in the presence of repetitive, short-duration arterial oxyhemoglobin saturation. (SaO2) fluctuations without any absolute or relative decrease in the SaO2 threshold. The diagnosis of SAHS was confirmed when the apnea-plus-hypopnea index was greater than 10. RESULTS: Based on the results of the polysomnographic sleep study, 110 patients had SAHS (apnea-plus-hypopnea index, 38.1 +/- 2.5/h; mean +/- SE). Home oximetry test results were interpreted as abnormal in 176 patients (this included 108 patients with SAHS and 68 without SAHS) and were read as normal in 62 patients without SAHS and in 2 with SAHS. Home oximetry testing had a sensitivity of 108/110 or 98.2% (95% Cl, 93.6% to 99.8%); a specificity of 62/130 or 47.7% (Cl, 38.8% to 56.6%); a positive predictive value of 108/176 or 61.4%; and a negative predictive value of 62/64 or 96.9%. CONCLUSIONS: A negative home oximetry test result is helpful in ruling out the diagnosis of SAHS in patients clinically suspected of having this syndrome, because a negative test result reduced the probability from 54.1% to 3.1% in our patients. However, a positive oximetry test increased the probability from 46% to 61.4% in our group of patients.     

Mammoplasty for symmetry of the contralateral breast and its oncologic value]

Although a broad range of neuropsychological deficits has been reported in patients with severe sleep disordered breathing (SDB), little is known about the impact of mild SDB on neuropsychological performance. In this study, we compared neuropsychological test performance in two groups of carefully screened volunteers who differed clearly according to the respiratory disturbance index (RDI). Controls (n = 20) were identified on the basis of an RDI < 5; cases (n = 32) had an RDI in the range of 10-30. Cases and controls were well matched with regard to IQ, age, and sex. Cases had significantly more self-reported snorting and apneas and a higher body mass index than controls but did not differ according to sleepiness as measured by either the multiple sleep latency test or the Epworth sleepiness scale. An extensive battery of neuropsychological and performance tests was administered after an overnight sleep study. Cases performed significantly more poorly on a visual vigilance task (perceptual sensitivity, d': 2.24 +/- 0.64 vs. 2.70 +/- 0.53, p = 0.01, for cases and controls, respectively) and a test of working memory, the Wechsler adult intelligence scale-revised digits backwards test (6.12 +/- 2.20 vs. 7.55 +/- 2.22, p = 0.02), than controls. The groups did not differ in their performance on other tests of memory, information processing, and executive functioning. In summary, subjects with mild SDB may manifest a vigilance deficit in the absence of substantial sleepiness. Subjects with a mildly elevated RDI (10-30) without sleepiness do not appear to suffer appreciable deficits in more complex neuropsychological processes (e.g. executive functions).     

The reliability of the diagnostic features in patients with narcolepsy

This study determined the test-retest reliability of the polysomnographic findings in narcolepsy. The diagnosis of narcolepsy was based on clinical symptoms and polysomnographic signs. Control subjects were screened before participation and were split based on their screening multiple sleep latency test (MSLT) into high- and low-MSLT groups. Subjects completed two polysomnographic evaluations with at least 5 days between laboratory tests. Narcoleptics had lower sleep efficiencies and high stage 1% when compared to the low MSLT control group. They had more awakenings and less stage 2% than the control groups. Narcoleptics had a shorter latency to 1 when compared to the high-MSLT group but comparable to that of the low-MSLT group. Narcoleptics had a higher number of sleep-onset rapid eye movement periods (SOREMPs) than both control groups. The MSLT scores were stable across the two evaluations and showed a statistically significant correlation. Twenty-eight of the 30 narcoleptic subjects had two or more SOREMPs on reevaluation. None of the controls had multiple SOREMPs. Thus, multiple SOREMPs were shown to be a reliable finding in patients with narcolepsy.     

Polysomnographic sleep is not clinically impaired in Vietnam combat veterans with chronic posttraumatic stress disorder

BACKGROUND: Because sleep is typically disturbed in posttraumatic stress disorder (PTSD), this study was undertaken to evaluate a group of Vietnam combat veterans with the disorder using clinical polysomnographic techniques. METHODS: Eighteen Vietnam combat veterans with PTSD and 10 healthy non-combat-exposed Vietnam era veterans participated in 2 nights of polysomnographic study and a multiple sleep latency test. RESULTS: No significant differences between subjects and controls were noted except for greater sleep onset latency to stage 2 (p < .03), and lower arousals/hour from stages 3 & 4 (p < .04) on night 2, and lower subjectively estimated total sleep time on night 1 (p < .005) in the case of PTSD subjects. Otherwise, results from the second night served to replicate those from the first, and no significant differences appeared on 2 successive nights for any polysomnographic variable. No daytime hypersomnolence was detected. CONCLUSIONS: Polysomnographically recorded sleep was notably better than expected in the presence of clinically significant PTSD with typical histories of disrupted sleep. In these subjects, there is no clinically significant sleep disorder or typical pattern of sleep disturbance detectable by standard polysomnography.     

Therapeutic leukapheresis in the patient with leukemia

OBJECTIVE: To predict and optimal level of continuous positive airway pressure (CPAP) in the menagement of obstructive sleep apnea syndrome (OSAS) by relating certain parameters of respiratory disturbance and sleep hypoxemia. METHODS: 18 patients with OSAS (all male, aged 48 +/- 11 yrs) were enrolled in the study. Their actual levels of CPAP (Pm) were determined by a RHK-5500 mode polysomnographic system plus BiPAP (ST/D) system. The actuual Pm was related to the respiratory disturbance index (RDI) or total time of SaO2 < or = 90% (T S90). The correlation regression equations were calculated. 6 patients with OSAS (Group A) were treated with the predicted nasal CPAP (predicted Pm) which was derived from the regression equation, 8-10 hours per night, for 5-7 nights. 13 patients (Group B) receiving nasal CPAP treatment using the actually measured Pm served as control. RESULTS: There was a close positive linear correlation between RDI or T S90 and actual Pm. Symptoms and polysomnographic parameters improved significantly after one course of CPAP treatment in Group A. The efficacy showed no signifcant different as compared with that in Group B. CONCLUSIONS: It was suggested that RDI or T S90 are of value and simple in predicting the pressuure level of CPAP in the management of OSAS with nasal CPAP.     

Prey selection in the leopard frog: choosing in biased and unbiased situations

We evaluated left ventricular function by echocardiography in a prospective study that included 98 consecutive human immunodeficiency virus (HIV)-infected patients and 40 HIV-seronegative normal controls. When compared with controls, HIV patients showed increased isovolumic relaxation time (101+/-18 ms versus 71+/-10 ms; p<0.0001) and left ventricular diastolic diameters (51+/-6 mm versus 47+/-3 mm; p<0.0005), and decreased fractional shortening (31+/-6% versus 37+/-2%; p<0.0001). Diastolic dysfunction was the most frequent finding (63% of the patients). We found depressed ejection fraction in 31 (32%) patients. Only 8 (8%) patients had symptomatic congestive heart failure. Left ventricular dysfunction was not attributable to intravenous drug abuse or to therapy. It was less severe in earlier stages of the infection (fractional shortening: acquired immunodeficiency syndrome=30%+/-6%, asymptomatic HIV-seropositives 34%+/-5%; p<0.005) and in HIV-2-infected patients. Patients with opportunistic infections (all aetiologies mixed) had more frequent congestive heart failure than those without infections (16% of the patients with versus 4% of the patients without infections; p<0.05). The fact that even asymptomatic HIV-seropositives had signs of left ventricular dysfunction (fractional shortening: asymptomatic HIV-seropositives=34%+/-5%; controls=37%+/-2%; p<0.05) favours the hypothesis of the HIV being one of the causes of these abnormalities.     

1997 Paul Ehrlich and Ludwig Darmstaedter Prize for the rediscovery of Helicobacter pylori to J. Robin Warren and Barry J. Marshall

The aim of this study was to: (i) test different instruments that focused on sleep, quality of life and personal adjustment in order to evaluate the usefulness of these instruments in a larger study; and (ii) to describe self perceptions of sleep and life situation by patients who had undergone coronary artery bypass grafting (CABG). A one-group pre-test repeated post-test design was used. Six men aged between 51 and 70 years were interviewed, and 24 h polysomnographic recordings were performed before and after the operation. The interviews indicated disturbed sleep and changes in behaviour and mental state immediately postoperatively. Postoperatively the polysomnographic recordings revealed a significant decrease in mean duration of sleep, mean percentage of stage 3-4 sleep and mean rapid eye movement (REM) sleep. One month after surgery the quality of life was improved, while moderate anxiety and sensation of incisional pain persisted. The measurements used in this pilot study provide valuable information into the understanding of altered sleep, quality of life and personal adjustment following CABG.     

Change in bacterial community during biodegradation of aniline

A modification of the standard electrodiagnostic test was developed in an effort to provide a more sensitive electrodiagnostic evaluation in radial tunnel syndrome. Radial motor nerve latency recordings were obtained in 3 different forearm positions: neutral, passive supination, and passive pronation. The maximal difference in these recordings, the differential latency, in 25 patients with radial tunnel syndrome of greater than 6 months duration (test group) was compared with those in 25 asymptomatic volunteers (control group). Differential latency recordings were obtained in all patients in the test group before and after surgery. Radial nerves that were compressed demonstrated a significantly greater differential latency (0.44+/-0.12 ms) versus controls (0.12+/-0.008 ms). Following radial nerve decompression, differential motor latencies in the test group decreased below control values, demonstrating a resolution of the provoked electrical response with a postoperative differential latency of 0.07+/-0.05 ms. Our results demonstrate the differential motor latency of the radial nerve to be a sensitive electrodiagnostic tool in patients with radial tunnel syndrome. A differential latency of > or =0.30 ms was considered indicative of radial tunnel syndrome.     

Concomitant radiotherapy with mitomycin C and bleomycin compared with radiotherapy alone in inoperable head and neck cancer: final report

We evaluated the efficiency of two different treatment procedures with continuous positive airway pressure (CPAP) on sleep, nocturnal breathing characteristics and daytime vigilance in 18 newly diagnosed patients with untreated sleep apnoea/hypopnoea syndrome (SAHS) randomly allocated to two different groups. In group I, the positive pressure (PP) level was set to suppress flow limitation (PFL), while in group II the PP was set at a level that eliminated only apnoea/hypopnoea and snoring (PAHS). At the end of a 3 week period of home CPAP therapy, a follow-up sleep study, vigilance and cognitive tests were made. Overall, PFL was significantly higher than PAHS values (PFL: 10.42.6 cmH2O; PAHS: 8.9+/-2.6 cmH2O; p<0.01, mean+/-SD). We found no difference in sleep quality, nocturnal saturation and apnoea/hypopnoea index, or in daytime vigilance tests between the two groups at the end of the treatment period. However, there was a significantly greater scattering in the changes of sleep latency in group II than in group I. This was associated with a significant difference in the daily duration of nasal CPAP use between the two groups (group I: 7.29+/-0.95 h x day(-1); group II: 6.01+/-0.94 h x day(-1); p=0.01) and with a positive correlation between final maintenance of wakefulness test values and the duration of CPAP use (p<0.05; r=0.55). These results tend to show that correcting flow limitation is associated with a higher observance and a more important efficiency in normalizing daytime vigilance than with conventional nasal continuous positive airway pressure.     

Protein-dependent reduction of the pyrene excimer formation in membranes

The study aimed at the evaluation of the gastric emptying (GE) kinetics in hypothyroid patients before and after a substitutive treatment with L-thyroxin. Twelve female hypothyroid (aged 45.3 +/- 8.7 years, mean +/- SD) and a control group of 12 healthy women (aged 34.5 +/- 8.1 years) were examined. The GE of a 99mTc-labelled solid meal was measured with the use of a gamma camera in every patient before the treatment, and in 10 of them a repeat GE examination was performed after the restoration of euthyroid; the median duration of the treatment was 5.5 mo (range 2.5 to 12 mo). The mean gastric transit time (MTT90) and the fraction of the test meal retained in the stomach after 90 min (F90) were statistically significantly greater in untreated hypothyroid than in healthy controls (MTT90: 42.01 +/- 1.86 min patients vs 40.06 +/- 1.00 min controls, p = 0.0043; F90: 64.3 +/- 15.4% patients vs 50.8 +/- 8.2% controls, p = 0.0173). In ten patients in whom a second GE measurement was taken after the achievement of euthyroid, a slight increase of the GE was observed (MTT90:41.46 +/- 1.49 min before vs 41.04 +/- 1.81 min after the treatment, NS) which was then no longer statistically significantly different from that of the healthy controls. No relationship was found between the GE and the severity of clinical symptoms of hypothyroidism. GE remained, however, slowed in some patients despite the restoration of euthyreosis. We conclude that: (I) long-lasting hypothyreosis is accompanied by a slightly slowed GE of solids, and (II) restoration of euthyreosis does not imply a parallel improvement of the hypothyroidism-associated delay in GE.     

Auto-CPAP treatment in obstructive sleep apnea syndrome: a prospective randomized study during initiation of treatment

OBJECTIVE: The efficacy and acceptance of self-regulated continuous positive airway pressure (auto-CPAP) ventilation was compared with conventional CPAP administration in the treatment of patients with obstructive sleep apnoea. PATIENTS AND METHODS: Using a cross-over design, under polysomnographic monitoring in a sleep laboratory, 25 patients with obstructive sleep apnoea underwent conventional CPAP or auto-CPAP treatment. Using a questionnaire, patients gave their assessment of its acceptability and efficacy after each treatment session. RESULTS: The mean pressure during treatment was the same in the two groups (7.2 +/- 1.9 versus 7.1 +/- 1.9 mbar; no significant difference). Maximal pressure during auto-CPAP averaged 3.7 +/- 2.1 mbar higher than during conventional CPAP ventilation. The mean apnoea-hypopnoea index (AHI) during auto-CPAP, 4.4 +/- 4.3 mbar, during auto-CPAP was significantly higher than during conventional CPAP treatment (2.8 +/- 2.8 mbar; P = 0.044). In eight patients on auto-CPAP an AHI of 5 or less could not be reached, while an AHI of 5 or less was obtained in all but three patients under conventional CPAP. In a subgroup of 17 patients, in whom a reduction of AHI to at most 5 was achieved with both conventional and auto-CPAP, analysis of sleep pattern and of arousals was similar with the two forms of ventilation. Several patients reported that with auto-CPAP falling in sleep was more difficult and they slept less well. None of the patients preferred auto-CPAP. CONCLUSION: By means of the auto-CPAP neither a pressure reduction nor an improvement in compliance could be achieved. Therapeutic effectiveness was significantly less as with conventional CPAP therapy.     

The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation

STUDY OBJECTIVE: To determine whether the use of continuous i.v. sedation is associated with prolongation of the duration of mechanical ventilation. DESIGN: Prospective observational cohort study. SETTING: The medical ICU of Barnes-Jewish Hospital, a university-affiliated urban teaching hospital. PATIENTS: Two hundred forty-two consecutive ICU patients requiring mechanical ventilation. INTERVENTIONS: Patient surveillance and data collection. MEASUREMENTS AND RESULTS: The primary outcome measure was the duration of mechanical ventilation. Secondary outcome measures included ICU and hospital lengths of stay, hospital mortality, and acquired organ system derangements. A total of 93 (38.4%) mechanically ventilated patients received continuous i.v. sedation while 149 (61.6%) patients received either bolus administration of i.v. sedation (n=64) or no i.v. sedation (n=85) following intubation. The duration of mechanical ventilation was significantly longer for patients receiving continuous i.v. sedation compared with patients not receiving continuous i.v. sedation (185+/-190 h vs 55.6+/-75.6 h; p<0.001). Similarly, the lengths of intensive care (13.5+/-33.7 days vs 4.8+/-4.1 days; p<0.001) and hospitalization (21.0+/-25.1 days vs 12.8+/-14.1 days; p<0.001) were statistically longer among patients receiving continuous i.v. sedation. Multiple linear regression analysis, adjusting for age, gender, severity of illness, mortality, indication for mechanical ventilation, use of chemical paralysis, presence of a tracheostomy, and the number of acquired organ system derangements, found the adjusted duration of mechanical ventilation to be significantly longer for patients receiving continuous i.v. sedation compared with patients who did not receive continuous i.v. sedation (148 h [95% confidence interval: 121, 175 h] vs 78.7 h [95% confidence interval: 68.9, 88.6 h]; p<0.001). CONCLUSION: We conclude from these preliminary observational data that the use of continuous i.v. sedation may be associated with the prolongation of mechanical ventilation. This study suggests that strategies targeted at reducing the use of continuous i.v. sedation could shorten the duration of mechanical ventilation for some patients. Prospective randomized clinical trials, using well-designed sedation guidelines and protocols, are required to determine whether patient-specific outcomes (eg, duration of mechanical ventilation, patient comfort) can be improved compared with conventional sedation practices.     

Gallbladder dyskinesia in acalculous biliary colic

AIMS: To test the hypotheses that: 1) postprandial gallbladder emptying might be abnormal in patients with acalculous biliary colic; and 2) that hymecromone, a drug that increases bile flow and relaxes biliary muscle might improve symptoms. METHODS: Twenty-four women were studied. Twelve patients presented recurrent biliary type of pain in the absence of gallstones, and persistence of contrast in the gallbladder, 24 hours after an oral cholecystogram, suggesting cholesterolosis. Twelve healthy volunteers used as controls had no symptoms and the gallbladder was not visible the day after an oral cholecystogram. Gallbladder emptying induced by an oral meal was studied with ultrasound in both groups before and after the administration of hymecromone. RESULTS: Gallbladder volumes were similar in both groups (23 +/- 10 ml vs. 31 +/- 11 ml; NS). Gallbladder emptying in the control group was simple exponential (R2 = 0.948 +/- 0.059) with a rate of 32 +/- 16 minutes. Gallbladder emptying was bimodal in patients. Gallbladder volume increased to 120% in the first 10 minutes, to empty exponentially thereafter (R2 = 0.964 +/- 0.040. Rate: 29 +/- 22 minutes). This resulted in a marked reduction in gallbladder volume emptied at 40 minutes when compared to controls (30% +/- 27% vs. 54% +/- 14%; p = 0.012). Pretreatment of controls with hymecromone induced an emptying pattern similar to that of patients. In patients, emptying after hymecromone did not change but symptoms were improved. CONCLUSIONS: An abnormal emptying pattern of the gallbladder was identified in patients with acalculous biliary colic, and hymecromone was partly effective to reduce pain, despite a minor effect on gallbladder emptying pattern.     

The 1994 Clinical Research Award. A prospective clinical study of the polysomnographic stages of sleep after burn injury

Although subjective evidence suggests that patients with burns are deprived of sleep, previous clinical studies have been limited to observational data and have not to date included electroencephalographic or polysomnographic recordings. The purpose of this study was to characterize the sleep pattern of patients suffering from thermal injury. Biweekly 24-hour polysomnographic measurements (electromyography, electrooculography, and electroencephalography) were performed with 12 leads. This measuring permitted continuous recording of intrinsic electrical activity in skeletal muscles via chin electrodes, eye movement via outer canthal electrodes, and brain wave activity with the other bipolar electrodes. Determinations were obtained on 11 patients with thermal injuries for a total of 43 24-hour periods. The patients had a mean age of 8.31 +/- 1.5 years (range 1.4 to 16 years), a mean total body surface area burn of 55.1% +/- 16.5% (range 17.5% to 90.5%), and a mean full-thickness burn of 48.5% +/- 8.1% (range 10.5% to 90.5%). Although mean total sleep time was seemingly adequate (625.1 +/- 31.6 min/patient/24 hrs), large aberrations in sleep stage distribution were noted. Significant decreases in stage 3 + 4 and in rapid eye movement (deep sleep) and increases in stages 1 and 2 (light sleep) were noted, suggesting a cycling back to stages 1 or 2 after disruption of sleep. Overall, in 43 runs 40% of the subjects were completely lacking stage 3 + 4, and 19% were missing rapid eye movement during an entire 24-hour run.(ABSTRACT TRUNCATED AT 250 WORDS)     

Leukocyte function in chronic myeloproliferative disorders

The myeloproliferative disorders (MPD) are clonal diseases that originate from a transformed stem cell and involve all myeloid lineage. The affected cells have both proliferative and functional impairment. Therefore, we evaluated and compared neutrophil function in 31 patients with polycythemia vera (PV), idiopathic myelofibrosis (MF), chronic myeloid leukemia (CML), and essential thrombocytosis (ET). Neutrophil chemotaxis, random migration, bactericidal activity and superoxide anion release in these patients were simultaneously compared to those of 31 healthy controls. In this study, chemotactic activity was significantly impaired in patients with PV and CML as compared to controls (M+/-SE: 42 +/- 6 vs. 69+/- 5 cells/field; p<0.005 and 47+/-7 vs. 68+/- 5; p<0.05, respectively). The assessment of the bactericidal activity of neutrophils showed no impairment in most of the patients. In the CML group, the serum had a very strong "lytic" effect on bacteria, possibly due to the high levels of serum lysozyme (22 +/- 2 microgram/ml). The superoxide anion release was found to be normal in most of the patients. Nevertheless, in 25% of PV patients the superoxide production was impaired (less than 60% of the simultaneous controls). In ET most patients had normal neutrophil function. Regarding the effect of treatment, neutrophil chemotactic activity was found to be significantly reduced in the hydrea-treated patients, as compared to the non- treated patients (p<0.001) or healthy controls (<0.0001). We conclude that disturbances in neutrophil function are present in patients with various MPDs, except ET. This probably reflects abnormal maturation of ancessors of the damaged stem cells. Nevertheless, we should keep in mind that therapy itself could affect neutrophil functions. This matter should be studied more extensively. Although infections are not common in MPD disorders, they occasionally occur. It is possible that impairment in the phagocytic function contribute to the development of infections in patients with myeloproliferative disorders.     

Transferrin receptor assay and zinc protoporphyrin as markers of iron-deficient erythropoiesis in end-stage renal disease patients

Nine girls with Rett syndrome (mean age, 10.1 years) were monitored 24 hours a day over a period of 10 weeks using wrist actigraphy. Baseline sleep-wake patterns were assessed for 1 week. Subsequently, patients underwent a 4-week melatonin treatment period in a double-blind, placebo-controlled, crossover protocol that employed a 1-week washout between treatment trials. Melatonin doses ranged from 2.5 to 7.5 mg, based upon individual body weight. Baseline sleep quality was poor compared with healthy children. At baseline the group demonstrated a low sleep efficiency (mean [+/- SE], 68.0+/-3.9%), long sleep-onset latency (42.1+/-12.0 minutes), and a short and fragmented total sleep time (7.5+/-0.3 hours; 15+/-2 awakenings per night). Melatonin significantly decreased sleep-onset latency to (mean +/- SE) 19.1+/-5.3 minutes (P<0.05) during the first 3 weeks of treatment. While the variability of individual responsiveness was high, melatonin appeared to improve total sleep time and sleep efficiency in the patients with the worse baseline sleep quality. Finally, a 4-week administration of melatonin appears to be a safe treatment as no adverse side effects were detected, yet long-term effects of chronic melatonin use in pediatric patients are unknown at this time.     

Heart and lung retransplantation: should it be done?

STUDY OBJECTIVES: To evaluate unattended full polysomnography (PSG) recorded in the home by the DigiTrace Home Sleep System (DHSS) and to assess the ability to acquire, store and analyze polysomnographic data using the DHSS compared to standard paper PSG. DESIGN: Part 1 used a prospective, cross-over design. Part 2 consisted of a prospective concurrent collection of polysomnographic data. SETTING: Sleep Disorders Center in a university medical center. PARTICIPANTS: All adult patients who required standard clinical PSG as part of their clinical evaluation, regardless of suspected diagnosis, except patients requiring video recording for abnormal behaviors. MEASUREMENTS AND RESULTS: The DHSS is a digital recording system with miniature preamplifiers and the capacity to record 18 channels of polysomnographic data, including 4 channels of EEG (C3-A2, C4-A1, C3-O1 and C4-O2), right and left EOG, two channels of chin EMG, ECG naso-oral airflow, respiratory effort (piezo crystal thoracic and abdominal belts and bilateral interacostal EMG), snore microphone, bilateral anterior tibialis EMG, and body-position sensor. In part 1,77 DHSS home recordings were evaluated. No recordings were lost due to equipment failure and each parameter was scorable in greater than 95% of all epochs. Most of the subjective assessments by questionnaire following each study revealed no difference between the two testing situations. However, patients reported more sleep time and a better overall test experience in the lab. Assessments of sleep quality and morning alertness compared to usual were rated higher in the lab. After completing both studies, more patients preferred the lab study (p < .01), mostly because of minor inconveniences and apprehension regarding acquisition of data during the home study. There was no difference in the assessment of which test most accurately represented their sleep. In Part 2, the DHSS recorded concurrently with paper PSG in the laboratory in 16 patients. The results show no significant differences for any parameter and strong positive correlations for all parameters. CONCLUSION: Using the DHSS, unattended full PSG can be performed in the home with reliable and high quality recordings. Full PSG can be extended to a larger patient population, because it is no longer limited by the number of beds, and there is a reduction in cost due to elimination of overnight staff and facility cost.     

Long-term evolution of daytime somnolence in patients with sleep apnea/hypopnea syndrome treated by continuous positive airway pressure

We demonstrated in a previous study that excessive daytime sleepiness (EDS) in patients who have sleep apnea/hypopnea syndrome (SAHS) and are undergoing continuous positive airway pressure (CPAP) treatment improved differently in two groups of patients: in group I, multiple sleep latency tests (MSLT) were normalized after 50 days of treatment (individual value > 10 minutes), whereas they remained low (individual value < 10 minutes) in group II, with a significant difference between groups. To evaluate the long-term evolution of daytime somnolence under nasal CPAP treatment, five patients from group I and seven patients from group II underwent a new polysomnography and MSLT 4 years after the previous study. Clinical, polysomnographic and MSLT results obtained at baseline before treatment (T1), after the initial 50-day period of CPAP treatment (T2), and after 4 years (T3) were compared. The significant difference in mean MSLT value between the two groups previously observed at T1 and T2 disappeared at T3 (group I: 12.4+/-5.9 minutes; group II: 9.7+/-5.9 minutes). We found that this long-term improvement in excessive daytime somnolence was independent of the initial MSLT value, the severity of SAHS, and the initial MSLT changes under nasal CPAP. Long-term MSLT evolution was significantly correlated to CPAP compliance. These results demonstrate that even in the absence of a significant increase in MSLT at the beginning of CPAP treatment, further improvement is still possible several years later, which may encourage the regular, long-term use of nasal CPAP by patients.     

Hypofunction of the stress axis in Sj?gren's syndrome

OBJECTIVE: To examine the functional integrity of the hypothalamic-pituitary-adrenal (HPA) and thyroid axes in Sj?gren's syndrome (SS) via the assessment of basal and stimulated adrenocorticotropin (ACTH), cortisol, thyroid stimulating hormone (TSH), and prolactin levels. METHODS: Pituitary function of the HPA axis was assessed by determining the basal plasma levels of ACTH in the late afternoon, as well as the ACTH released to ovine corticotropin releasing hormone (oCRH) stimulation; adrenal function was assessed by measuring plasma cortisol levels in the late afternoon at baseline and after release of the endogenous ACTH during oCRH stimulation. Basal and thyrotropin releasing hormone (TRH) stimulated levels of TSH and prolactin were also assessed. Healthy volunteers were used as controls. RESULTS: Patients with SS, compared to controls, were characterized by significantly lower ACTH levels (pg/ml), (5.1 +/- 0.5 vs 11.4 +/- 1.5, respectively; p < 0.05) and cortisol levels (microg/ml), (2.4 +/- 0.6 vs 5.9 +/- 1.2, respectively; p < 0.05). Furthermore, a blunted pituitary and adrenal response to oCRH compared to controls was observed: peak plasma ACTH and cortisol levels for patients with SS were 46.2 +/- 5.4 pg/ml and 15.7 +/- 1.6 microg/ml, respectively, and for controls 61.5 +/- 3.8 and 19.6 +/- 0.7, respectively (p < 0.05). Basal TSH levels were significantly elevated in patients (1.3 +/- 0.3 microIU/ml vs 0.9 +/- 0.05 microIU/ml; p < 0.05). CONCLUSION: The above findings indicate hypoactivity of the HPA axis in patients with SS. Further studies are needed to definitively identify the locus of the defects and assess the significance of the pattern of the perturbations to the pathogenesis and expression of SS.